How is it diagnosed?

Alzheimer's disease

Introduction

Alzheimer's disease is a form of dementia but is not necessarily caused by the same factors which cause other forms of dementia. However, despite a considerable amount of research, the actual cause of the disease remains unknown. There is no single test to determine whether someone has Alzheimer's disease. It is diagnosed by a process of elimination, as well as a careful examination of a person's physical and mental state, rather than by finding actual evidence of the disease.

A carer or relative may be asked to provide information about the person's behaviour, e.g. difficulties getting dressed, washing, handling finances, keeping appointments, travelling alone, managing at work and using household appliances. A neuropsychological assessment is usually carried out. This involves finding out about possible problems with memory, language, planning and attention. A simple test called the Mini-Mental State Examination is often used. This involves the person being asked to answer questions such as: What is the date? What city are we in? What is this called? (shown a watch). Another part of the test is to follow a series of simple instructions.

A number of tests may be carried out (e.g. blood and urine samples) in order to rule out the possibility of other illnesses which might explain the dementia syndrome or illnesses which might aggravate an already existing case of Alzheimer's disease. In addition to this, a few methods of brain imaging have been developed which produce images of the living brain, thereby revealing possible differences between the brains of people with Alzheimer's disease and those of non-affected individuals. These tests provide a risk-free and pain-free means of examining the brain of a living person. Although they cannot lead to a certain diagnosis of Alzheimer's disease, some doctors may use one or more of these techniques to give more weight to a diagnosis.

Methods of brain imaging

Magnetic Resonance Imaging This permits an extremely detailed image of the brain's structure. When one image is placed over another, taken a few months' later, it is possible to see changes at an early stage in a certain part of the brain.

CT (Computed Tomography) Scanning This measures the thickness of a part of the brain which becomes rapidly thinner in people with Alzheimer's disease.

SPECT (Single Photon Emission Computed Tomography) Scanning This can be used to measure the flow of blood in the brain, which has been found to be reduced in people with Alzheimer's disease as a consequence of nerve cells not working properly.

PET (Positron Emission Tomography) The use of this scanning technique is often limited to research settings. It can detect changes in the way the brain of someone with Alzheimer's disease functions. It can, for example, detect abnormal patterns of glucose usage by the brain.

The importance of an early diagnosis

Although it is not possible to accurately predict dementia, it is extremely important that people who have dementia obtain an early diagnosis. It is only by obtaining a diagnosis that the correct medical treatment can be prescribed. Existing drug treatment is most effective in the early stages, so delaying diagnosis prevents people from benefiting from the latest medical advances, which in many cases lead to a temporary improvement of symptoms.

However, memory problems are not always a sign of dementia. Although mental faculties change with age, ageing is not synonymous with dementia. Many older people need more time to assimilate information and this may affect their capacity to learn and remember things. Nevertheless, older people are often worried about these changes and are afraid that they might be developing dementia.

At the same time, many people do not know what the symptoms are. This is not surprising, as different kinds of dementia have different symptoms. Furthermore, some forms of dementia (e.g. Alzheimer's disease) are insidious. The following table describes some of the early symptoms of different kinds of dementia.

The presence of one or more of these symptoms does not necessarily mean that a person has dementia. In fact, in the case of older people, the symptoms of depression are very similar to those observed in the early stages of dementia and it is not uncommon for the two to be mixed up. Sometimes, the symptoms are linked to other disorders such as thyroid gland dysfunction, lack of vitamin B12, disorders of the metabolic system, alcohol or drug abuse, infections, surgical operations, stress and intolerance of medication. In such cases, the symptoms may be reversible.

A differential diagnosis is clearly essential in order to rule out other causes for the symptoms experienced and correctly diagnose dementia. In case of concern, the family doctor/general practitioner should be consulted. He or she will carry out a few tests and if his/her suspicions are confirmed refer the person concerned to the relevant specialists for further tests.

What are the different kinds of diagnosis?

There are three possibilities for a diagnosis of Alzheimer's disease : possible, probable and certain Alzheimer's disease.

Possible Alzheimer's disease

A diagnosis of possible Alzheimer's disease is based on the observation of clinical symptoms and the deterioration of two or more cognitive functions (e.g. memory, language or thought) when a second illness is present which is not considered to be the cause of dementia, but makes the diagnosis of Alzheimer's disease less certain.

Probable Alzheimer's disease

The diagnosis is classed as probable on the basis of the same criteria used to diagnose possible Alzheimer's disease, but in the absence of a second illness.

Certain Alzheimer's disease

Identification of characteristic plaques and tangles in the brain is the only way to confirm with certainty the diagnosis of Alzheimer's disease. For this reason, the third diagnosis, that of certain Alzheimer's disease, can only be made by brain biopsy or after an autopsy has been carried out.

Should the person be informed of their diagnosis?

Nowadays more and more people with Alzheimer's disease are being informed of their diagnosis. This is perhaps due to a greater awareness of the disease. Some people might not want to be informed of the diagnosis. However, it is generally considered that everyone should have the right and be given the opportunity to decide whether they would rather know or waive this right. There are pros and cons involved in informing someone of their diagnosis. Also once the decision has been made to inform someone about their diagnosis the problem may arise of how to inform the person.

Pros and cons of telling the person

In many cases a diagnosis is made as a result of concern expressed by members of the family. Often the person with dementia is unaware or does not agree that they have a problem. They are therefore not interested in obtaining a diagnosis. Some might feel depressed about knowing or feel that they would have been happier not knowing. However, there are many advantages to knowing. When a person knows that they have Alzheimer's disease and understands what it involves, they can plan how to make the most of the remaining years of relative unimpaired mental functioning. They can also take an active role in planning their care, arrange who will care for them, make important financial decisions and even decide to participate in research or make the necessary arrangements to donate brain tissue after their death for research.

How to inform the person of the diagnosis

Some relatives and friends may find it difficult to approach the subject. Some people would prefer to be told privately on a one-to-one basis, whereas others might find it more reassuring to be told in the presence of their family, who could give them moral and emotional support. Another possibility is to arrange for the person's doctor to tell them. It might help to arrange to go to the doctor together or for the person to go alone. The doctor could then answer any questions that either the carer and/or the person with dementia might have. The way the diagnosis is explained will depend on the person's ability to understand. Some people might understand an explanation of what the disease is, how it tends to progress and the consequences for daily living, whereas others might only be able to grasp that they have a disease which involves the loss of memory. Once informed, they may need support to come to terms with feelings of anger, self-blame, fear and depression. Some might be able to benefit from counselling and support groups, provided that the disease is not too far advanced.